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For generations, tobacco paid the way to a better life
in eastern North Carolina. Now, tobacco companies are
paying millions into a trust fund, led by an ECU doctor,
that is addressing health problems caused by tobacco


Scroll down to watch a video presentation of this story

By Marion Blackburn  *  Photography by Forrest Croce

 Tobacco Field

A
fter a long, snowy winter, spring arrived in eastern North Carolina with freshly plowed fields dotted with tiny tobacco plants shooting up in perfect rows. If you were raised east of Raleigh, this pastoral scene likely evoked deep memories of hard work and reward. You may even know firsthand that for generations, when it was time for children of farming families to attend college—many of them the first in the family to do so—the tuition money came from the back-breaking work of pulling sand lugs, looping leaves to poles and then packing the crop into tin-roofed barns for curing.

Today, tobacco is still paying the bills in eastern North Carolina, though not in traditional ways. With funding each year from tobacco companies, North Carolina has set up two agencies dedicated to improving life in formerly tobacco-dependent counties.

Magazine CoverOne of them, the North Carolina Health and Wellness Trust Fund, focuses on improving health and especially preventing smoking and tobacco use. It is now headed by ECU’s own Dr. Charles Willson, who followed Gov. Beverly Purdue in the role. Willson, a pediatrician at the Brody School of Medicine and former president of the North Carolina Medical Society, is bringing a spirit of change to the trust fund, combined with a powerful mission to reduce smoking rates among youth.

“There is a proud heritage of tobacco in eastern North Carolina, but over the years, we have realized that tobacco was causing illness, and that tobacco use was the leading cause of preventable illness in North Carolina,” he says. “I love the tobacco heritage, but it’s time to put that aside and move forward.”

No one doubts that tobacco made the difference in eastern North Carolina, where communities prospered despite isolation and a lack of jobs. Greenville and Pitt County were once the largest producers of flue-cured tobacco in the nation, most of it high-quality bright leaf, and that windfall reached far into the community. Whether you worked in the fields pulling the slide beside a mule or ran a restaurant or country store that sold Pepsis and Cokes to hot, tired workers, you benefitted from it.

Today we know that profitable crop brought serious consequences to those who used it. In fact, smoking is so harmful the tobacco companies agreed in 1998 to send billions back to states to help them deal with its effects. This agreement, known as the Master Settlement, left North Carolina with an estimated payout of $4.6 billion through 2025.

A quarter, or about $1.15 billion, funded the Health and Wellness Trust Fund (HWTF), operating under the North Carolina State Treasurer. The first commissioners were appointed in 2001 and were led by Perdue until June 2009, when Willson assumed leadership. Based in Raleigh, it has allocated about $199 million for preventive health and $116 million for prescription drug assistance statewide, with about $5.3 million coming to the Greenville and Pitt County area in the past several years.

The HWTF has funded high-profile media campaigns that have been successful in reducing teenage smoking in North Carolina. One is the compelling Truth/Reality/ Unfiltered campaign (www.realityunfiltered.com) and its TRU TV public service ads featuring, among others, a young Asheville woman who lost her voice box to cancer. The foundation also is aggressively targeting obesity. In addition, it funds medication assistance for the elderly, mental health programs and efforts to eliminate health disparities arising from ethnicity or race.


Timeline                                          

N.C. Health and Wellness Trust Fund

2000


N.C. General Assembly creates trust fund to dispense one-quarter of state’s tobacco settlement money.
Chuck Willson is among original 18 commissioners.

HWTF sets10-year goal of reducing middle school
smoking rate to 7.5%.

2003


HWTF Launches youth smoking prevention program.

High school smokeless tobacco use 9.5%

Middle school smokeless tobacco use 4.5%

2005


Survey finds 41% of pupils have seen teacher or other
school official smoke on school grounds.

HWTF launches tobacco-free schools program.

N.C. raises cigarette tax from 5 cents to 35 cents per pack.
A year later, consumption declines 18%

2007


10.5% of middle schoolers think tobacco is “cool.”

2008


HWTF launches $12.6 million effort to reduce health disparities in diabetes

2009


Chuck Willson elected HWTF chair

115 out of 115 school district in N.C. are tobacco-free

N.C. raises cigarette tax to 45 cents

Beating 10-year goal, middle school smoking rate drops to 4.3%

Middle school smokeless tobacco use drops to 3.0%


Smokeless tobacco use down slightly to 8.5%

High school rate drops to 16.7%, lowest on record, on track to meet 10-year goal

Red flag: 15.4% of middle schoolers think smoking is “cool”

Change since 2003

Middle school smoking rate down 52.7%

High school smoking rate down 38.8%
Willson sees the foundation’s goals in personal terms, to “help people lead healthier lifestyles, so we could try to do what we all want to do—have the longest, most productive life we possibly can, so when the end comes, it doesn’t come from a form of cancer, or severe emphysema, with oxygen tanks, strokes, heart disease or congestive heart failure that tobacco has been known to cause.”

The settlement created another trust, the Golden LEAF, based in Rocky Mount, to fund economic development in formerly tobacco-dependent areas. The East Carolina Heart Institute, the new Family Medicine Center and the metabolic institute are among the Golden LEAF recipients.

These two foundations represent a new chapter in eastern North Carolina’s long and complicated relationship with tobacco. It’s a relationship typified by long-time Pitt County tobacco grower Lawrence Davenport, a former chair of both the Golden LEAF Foundation and the Pitt County Memorial Hospital Board of Trustees.

“If you go to other farming areas of the country, and see their homes and lifestyles, and compare it to what we have here in rural areas, there’s a tremendous difference and it’s all because of tobacco,” Davenport says. “If we had not had that industry here, I don’t think ECU would be here,” he adds. “The people who made money off tobacco wouldn’t have been here to fight to get it here. Then, the support that tobacco gave, from the donations, and the tax base here for the last 100 years—it has all been tobacco dependent. Everything came from tobacco. If not for tobacco, we wouldn’t be here.”

Despite the bounty tobacco brought the East, Willson says the time has come to shift our health habits. “Raising tobacco is an art,” he says. “I watch my neighbor do it every year, and tobacco growing in a field is wonderful, but it does cause these health problems. We need to move beyond that and get into healthier lifestyles.”


The problems


An estimated 12,200 adults die each year from tobacco use in North Carolina, the trust fund reports. About 1,500 people die each year who don’t even use it; they die from secondhand smoke. Nationally, 400,000 tobacco users die and another 50,000 perish from second-hand smoke each year.

In eastern North Carolina, smoking causes even more damage. Cancer could soon become the number-one cause of death in eastern North Carolina and in the state from its current number-two spot, according to the ECU Center for Health Services Research and Development, which works with researchers to gather and analyze information about health needs and status in eastern North Carolina and the state. In all, the death rate from cancer here is 9 percent higher than in the rest of the state.

Among cancers in eastern North Carolina, those closely linked with tobacco use (cancers of the throat and lungs) are the top cause of death. Those cancers continue to be higher here than elsewhere in the state, and while they are going down among men, evidence shows the death rate from them among white women is increasing. In terms of the regional disparity, there is hope: the lung cancer mortality rate for eastern North Carolina is decreasing, and at slightly faster rate than for the rest of the state.

Women are a special focus of many anti-smoking efforts by the Health and Wellness Trust Fund, which has largely keyed in on young people for meaningful prevention. The commission successfully eliminated tobacco on school campuses through the Tobacco-Free Schools program which began in 2003 and today boasts that all the state’s 115 school districts indeed are tobacco free.

No doubt the highest-profile effort has been stripping smoking of its coolness among teenagers. The HWTF launched a major anti-smoking campaign across the state known as “TRU,” or Tobacco. Reality. Unfiltered.

TRU television spots introduced viewers to the heartbreaking story of Reena Roberts, a young woman who began smoking at 13 and lost her voice box to throat cancer at 21. The striking image of her youthful appearance and the grating, mechanical sound of her synthesized voice provided immensely compelling evidence that cancer knows no age limits. Her story reached teenagers who may have thought tobacco’s dangers only happened after years of use—or to older people.

“One of the most powerful ads is when she says what she regrets most is her children will never hear her voice,” Willson says.




Tobacco Barns

The programs


Naturally the primary goal of the Health and Wellness Trust Fund is reducing smoking.

In addition to the Tobacco-Free Schools and TRU campaigns, the trust fund has awarded more than $29.4 million in Teen Tobacco Grants since 2003. These grants use peer groups to give presentations about smoking and support for quitting while pushing for tobacco controls especially for young people. While there are no Teen Tobacco grant funded programs in Pitt County, another program, Question Why (?Y) has instructed young people from the area as anti-smoking peers.

These efforts have paid off. While smoking was already going down among young people in the years 1999–2003, since these campaigns started the rate of decrease has accelerated. Smoking went down more than 30 percent among high school students in 2003–2007 and dropped by more than 51 percent among middle school students in those same years.

“There are naysayers, who doubt that prevention works,” says Vandana Shah, who until early March of this year served as the executive director of the Health and Wellness Trust Fund. “The fact that we managed in less than six years to cut those (middle school smoking) rates in half has been heartening that, yes, we can make a difference.”

The next major push is obesity prevention. Many health experts consider childhood obesity a greater threat than smoking, given its recent decline. In North Carolina, two-thirds of all adults (65.7 percent) are overweight or obese, according to Eat Smart, Move More North Carolina, an organization working to improve these numbers. The group notes that North Carolina ranks fifth worst nationally for childhood obesity.

Overall, 6 percent of all health care expenses in the state were related to obesity in 2003—that’s $2 billion, according to The Burden of Obesity in North Carolina, a report from the state Division of Public Health.

When you consider that threat within the area’s overall health condition—in 2007 the death rate in eastern North Carolina was already 6 percent higher than the state rate, which was itself 1 percent higher than the national average—the need for action appears even more urgent.

“We ought to be able to control obesity, which is an epidemic,” says longtime health educator Don Ensley, associate professor and director of graduate programs in the College of Allied Health Sciences. “Obesity is the next frontier, along with smoking and tobacco use. Obesity is creating havoc in public health.”

Ensley wonders if we should tax the food industry, as with cigarettes, to recoup the costs of obesity’s lethal effects. Because overeating, like smoking and other addictive health habits, comes down to a choice, whether or not it’s an easy one, Ensley says education and awareness may not be enough to make a difference.

“You have people who say, ‘I’m going to do what I want to do. It’s my body.’ Those are the people we need to address,” he says. “They don’t recognize that others are paying for their health through cost shifting. It’s like seat belts. When we say you’ve got to wear a seat belt or a motorcycle helmet, it’s because when you are hurt, I will have to pay for your accident or our tax dollars will pay for it.”

The trust granted ECU’s Brody School of Medicine more than $250,000 for IN4Kids, a program studying whether having nutritionists in community clinics helps reduce childhood obesity, and whether, if they are successful, they can be funded in the long term. It is in place at the state’s four medical schools.

In addition, the medical school received nearly $500,000 to study the Fit Together grant program. The university’s Department of Health Education and Promotion, part of the College of Health and Human Performance, received about $200,000 to study the A+ Fit School Designation Program.

Reflecting on the fund’s ambitions and accomplishments, Gov. Purdue hails the advances it’s made possible.

“The North Carolina Health and Wellness Trust Fund is a leader in fighting obesity, eliminating health disparities and reducing teen smoking,” Perdue said in a statement for this article. “That’s why I, along with the rest of the trust fund, did something that nobody thought we could do by reducing the number of teen smokers in North Carolina by more than 50,000 since 2003. North Carolina is healthier today in no small part because of the work done by the Health and Wellness Trust Fund.”

Yet the trust faces serious threats from budget shortfalls, which have driven state lawmakers to rob it for other state needs. Since 2002, state lawmakers have diverted more than $489 million from the trust to the General Fund for other needs, says Barbara Moeykens, social marketing and communications director.  

We’re not alone. A study released in December 2009 by the Robert Wood Johnson Foundation showed that in fiscal year 2010, states will collect about $25 billion in revenue from the tobacco settlement and tobacco taxes, but will spend barely 2 percent of it—$567.5 million—on tobacco prevention and cessation programs. Only North Dakota currently funds tobacco prevention at the level recommended by the U.S. Centers for Disease Control and Prevention.


Dr. Dale NewtonThe future


Hanging in his dining room is a large painting of a tobacco harvest, which Dr. Dale Newton (right) admits may seem strange for a doctor. Newton, a professor of pediatrics, clinical professor of medicine and vice chair of pediatrics, well knows the harmful effects of tobacco use, but he also knows it defined life in eastern North Carolina for decades.

His own family grew tobacco in Vance County, and among his many childhood jobs was pulling the slide, or leading a mule with a sled of leaves behind it.

“We didn’t carry it into market in sheets, we were still hand bundling it,” he remembers. Farmers graded their own tobacco, he says, after making a fist-sized ball from the golden leaves. “It was a beautiful aromatic display, and farmers were so proud when they were on the warehouse floor. It was an event to go to the auction. My father took me out of school, so I could experience it.”

That pride derived from the sweat of hired help and family members like himself. “It was very labor intensive,” he says. These days, he’s happy to be a physician. “It’s a lot less work.”

As a pediatrician and internal medicine physician, he regularly sees the ravages of tobacco use, which includes chewing. He compares nicotine addiction to drugs like cocaine or heroin. With teenagers, he admits, you can’t simply say, “Don’t smoke, it’s dangerous,” and expect to see results.

“One of the challenges is that when you talk about future risks, it doesn’t work with adolescents,” he says. “You have to frame it in terms of something more immediate, such as, ‘The most popular students don’t smoke.’ That you’ll get cancer carries no weight at all. You don’t ask, ‘Do you smoke?’ You ask, ‘Do your friends smoke?’ It’s safe for them to say, ‘Yes, a couple of friends smoke.’”

Changing attitudes from the ground up will take time, a redefinition of our culture Willson compares to other great historical shifts.

“When you look at the history of our economy, there was pain when we went from the horse-drawn carriage to the automobile,” he observes. “Change is inevitable. If we find that a product is causing so much disease—shortened life span, disability and death—it’s important that we move on beyond that.”